Healthcare Provider Details

I. General information

NPI: 1578659967
Provider Name (Legal Business Name): LISA G MARIN DMD, MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DR. LISA G HUDDLESTON

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 04/19/2023
Certification Date: 04/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 JOHN WESLEY GILBERT DRIVE
AUGUSTA GA
30912-0001
US

IV. Provider business mailing address

1430 JOHN WESLEY GILBERT DRIVE
AUGUSTA GA
30912-0001
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-9744
  • Fax: 706-721-6778
Mailing address:
  • Phone: 706-721-9744
  • Fax: 706-721-6778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number046876
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN010898
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: